Visiting Merlion: iCoViP project dissemination in Singapore

by Andrzej Kononowicz, Jagellonian University, Krakow

In February 2023, when parts of Europe were still covered with a thick layer of snow, Andrzej Kononowicz, one of the iCoViP team members from Jagiellonian University, visited Lee Kong Chian School of Medicine in Singapore (LKCMedicine) to conduct a seminar lecture entitled: “Digital clinical reasoning education: where are we now, where should we go?”. Singapore, a city-state in South-East Asia, is located on several islands that are passed by a myriad of cargo ships. The climate characteristic for places near the equator is humid with a temperature of 30°C around the year, a pleasant change for a visitor from a country with long and cold winters.

LKCMedicine is a new medical school in Singapore, the outcome of a partnership between Nanyang Technological University and Imperial College London. The school officially opened in 2017 but admitted its first students already in 2013. The location of the university in one of the most densely populated areas in the world and the crossroad between the East and the West gives it an opportunity to be a meeting place for scientists and students from many cultures and backgrounds to improve healthcare for the well-being of patients. High among the goals of the university is excellence in medical research and the education of future healthcare professionals.

The host of the visit was professor Josip Car, who leads at LKCMedicine the Centre for Population Health Sciences (CePHaS). His research group forms one of the WHO collaborating centers for digital health education. The former joint work of Josip Car and Andrzej Kononowicz included two systematic reviews on the effectiveness of virtual patients and virtual reality. The current visit was a good opportunity to present recent developments in the field of technology-enhanced clinical reasoning education. The visit also included meetings with other experienced researchers like Professor Jennifer Cleland, Vice Dean for Education and Director of Medical Education Research at Lee Kong Chian School of Medicine, as well as Assistant Professor Lorainne Tudor Car who leads a research team in the area of Evidence-Based Medicine and is experienced in research synthesis on digital education for healthcare workforce development.

In his seminar, Andrzej Kononowicz showcased how the longitudinal blended-learning clinical reasoning curriculum produced by the DID-ACT project was extended by a collection of virtual patients for deliberate practice designed by the iCoViP project. Emphasized was the systematic development process of the international pool of virtual patients that involved the selection of cases characterized by many clinical and socio-demographic features being representative of the European population. The multi-step development workflow illustrated how complex it is to author virtual patients in an international team. Considering the former collaboration and extensive expertise in the literature review of the hosts, an important point was also to share the approach taken by the iCoViP project to produce guidelines for the integration of the virtual patient into medical curricula.

The discussion that followed the presentation was an inspiring moment for consideration of what should be the next steps and points for a potential future collaboration after the iCoViP project has ended. It was commented that even though the number of 200 cases in the collection is a remarkable achievement, it is by far less than the number of existing diseases. We discussed whether artificial intelligence could be used to help increase the number of available cases. The other questions regarded the potential of learning analytics to optimize the use of virtual patients from the collection. Finally, it was also considered how applicable this collection could be for use in South-East Asia.

Even though the short, four-day stay at LKCMedicine was filled with many exciting meetings with researchers at Nanyang Technological University, there was also a bit of time to experience Singapore and its many attractions. Unforgettable is the view of the bay with the iconic ArtScience Museum, Marina Bay Sands hotel, and Gardens by the Bay. A deeper impression of the spirit of Singapore gave a walk through the primary forest around the MacRitchie Reservoir, visits to Chinatowns and Little India districts, as well as the view from Sentosa island on the Singapore Strait. The city bay is guarded by Merlion, a mythical creature with the head of a lion and the body of a fish that is symbolic of the history and character of the city. Despite its stern look, there might also be some curiosity in the way the Merlion statue observed the visitor from Europe. We hope that the presented outcome of the iCoViP project will inspire and enhance the education and research endeavors of our welcoming hosts in Singapore.

Phase of the curriculum	4th year of medical school
Goal in the curriculum	The iCoViP collection was implemented to practice selected VPs in the subject of Occupational Medicine (a voluntary subject in the University of Zaragoza in the 4th year of medical school).
Effective use of resources	The collection was used asynchronously so it was not necessary to have a computer infrastructure or a specific room and all students in Spain have laptops or access to the medical school computers. However, issue of updating content not yet solved.
VP alignment	The collection is used while students are doing their clinical placements having a teacher revising the responses and explaining to students most frequent mistakes.
Prioritization/relevance	For Occupational Medicine, the use of the iCoViP collection was a mandatory assignment needed to pass, but did not add points to the final grade.
Relation to other learning activities	None
Time allocation	One week was given to complete the assignment but more time was available for those who wanted to do the activity remote from home.
Group allocation	Students worked alone at home, when the educator discussed the solution of the VP, it was allocated in class (face-to-face or online).
Presence mode	Asynchronous
Technical Integration	It was integrated into Moodle.
VP use orientation/training	VPs were related to a specialty of medicine, but were randomly assigned to students regardless of where in the specialty they were rotating at the time.
Technical infrastructure	We used the technical infrastructure of the iCoViP project without any additions at the University of Zaragoza.
Learning activities around VPs	The teacher explained each VP and how to resolve them after getting the responses of all the students.
Assessment	Students had to complete the VPs, but there was no grade at the end. Only credit (pass/fail).
Quality assurance, maintenance, and sustainability	Frequent revision of the VPs by medical doctors.

Phase of the curriculum	Year 3 and 4 of medical school
Goal in the curriculum	Students learn basic steps of clinical reasoning including identifying relevant findings, developing differential diagnoses, deciding about a final diagnosis, ordering tests to rule out / confirm differentials, and suggesting treatment options.
Effective use of resources	Course tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs
VP alignment	VPs were part of the modules (e.g. Abdomen, cardiovascular system, pulmonary system, etc.) in year 3 and 4 of medical school and aligned with the objectives of these modules based on key symptoms. In addition a pool of 41 VPs was available for deliberate practice across key symptoms and diagnoses.
Time allocation	5 VPs / module
Group allocation	Students could choose whether to work in groups or individually.
Presence mode	Students could decide when and where to work on the VPs during the period of the module.
Technical Integration	VPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/training	No specific familiarization, but general introduction at the beginning of year 3.
Learning activities around VPs	Depending on the modules other learning activities were embedded.
Assessment	The topics of the VPs were part of modules assessment.
Quality assurance, maintenance, and sustainability	We used the built-in feedback functionality to receive qualitative feedback from students and VPs were part of the regular evaluation activities of the medical school.

Phase of the curriculum	Year 1 and 2 of medical school
Goal in the curriculum	Students learn basic steps of clinical reasoning such as identifying & prioritizing findings and composing a summary statement. They also can follow the reasoning process of the VP author concerning differential diagnoses, ordered tests, and treatments.
Effective use of resources	Course tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs.
VP alignment	VPs were part of the longitudinal clinical course and aligned with the other modules in year 1 and 2 (In case of Augsburg this was Contact, Movement, and equilibrium). We aligned the key symptoms of the VPs with these modules, so that students worked in parallel on these VPs and the corresponding module.
Time allocation	15 VPs over two years / 5 VPs per module.
Group allocation	Students could choose whether to work in groups or individually.
Presence mode	Students could decide when and where to work on the VPs during the period of the module.
Technical Integration	VPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/training	At the beginning of year 1 students were introduced into clinical reasoning and how they can train this ability with VPs.
Learning activities around VPs	Depending on the key symptoms during the longitudinal clinical course other learning activities were embedded.
Assessment	The topics of the VPs were part of the clinical longitudinal course assessment.
Quality assurance, maintenance, and sustainability	We used the built-in feedback functionality to receive qualitative feedback from students and VPs were part of the regular evaluation activities of the medical school.

Phase of the curriculum	Basic sciences/pre-clinical years: - At Jagiellonian University Medical College in Kraków we have integrated it in the “Introduction to Clinical Sciences” course in 2nd year of medicine. - At University of Porto in the “Propedeutics/Semiology” course in the 3rd year of medicine.
Goal in the curriculum	- To provide the students with an opportunity to challenge their knowledge at home in between classes with an interactive, clinical-oriented task. - To support learning by linking basic science knowledge with clinical reasoning. Students had the opportunity to practice on undiagnosed cases the skill of differentiating common symptoms, such as dyspnea, abdominal pain, headache.
Effective use of resources	Use of iCoViP VPs in native language of the students. No extra cost needed.
VP alignment	- In Kraków we have selected a few VPs (seven) with common diseases (e.g. pneumonia, pancreatitis, pulmonary embolism) with common symptoms. - In Porto, VPs are chosen according to the common symptoms to promote clinical reasoning.
Prioritization/relevance	- In Kraków the completion of all VPs is mandatory. - In Porto, VPs are introduced on a voluntary basis and are available on demand.
Relation to other learning activities	We used the time students had at home between seminars (Kraków: between on-campus based PBL sessions). VPs were spaced-activated (a new VP appeared biweekly synchronized with changing topics of the PBL seminars that focus on different leading symptoms).
Time allocation	Around 30 minutes biweekly, repeated 7 times in a semester.
Group allocation	Students worked alone at home to reflect but could consult the VPs with their peers or instructors in small groups of the face-to-face PBL seminars.
Presence mode	Students worked on the VPs asynchronously and self-directed at home to have time to reflect and consult textbooks.
Technical Integration	VPs were integrated with a course to which all students were enrolled on the official university learning management system Moodle using Learning Tools Interoperability (LTI) interface.
VP use orientation/training	Students were provided with an introductory email with instructions and had additionally the opportunity to technically practice using CASUS in a parallel “Telemedicine” (Medical informatics) course. Instructors received test-codes to practice the VPs at home.
Technical infrastructure	Students used their own computers from home. An email address was provided to a person responsible for technical support.
Learning activities around VPs	Students were asked to complete concept maps for all VPs they solve. Moreover, in Kraków students were provided with links to additional online articles to help them with topics difficult at this stage of education.
Assessment	Students were asked to complete the cases prior to the end of the term. They were not given grades for the activity - just credit. Their answers were randomly inspected to see common mistakes and provide general feedback to all students.
Quality assurance, maintenance, and sustainability	We checked the diagnostic accuracy of individual cases (and detected one case with imprecise diagnosis). Students evaluated the course using the iCoViP case collection evaluation questionnaire.